Guidance

About this guideline

About this guideline

NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions.

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.

This guideline was developed by the National Clinical Guideline Centre, which is based at the Royal College of Physicians. The Collaborating Centre worked with a Guideline Development Group, comprising healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, which reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation.

The methods and processes for developing NICE clinical guidelines are described in the guidelines manual.

NICE produces guidance, standards and information on commissioning and providing high-quality healthcare, social care, and public health services. We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland. Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.

Update information

[new 2014] indicates that the evidence has been reviewed and the recommendation has been added or updated

[2006] indicates that the evidence has not been reviewed since 2006

[2006, amended 2014] indicates that the evidence has not been reviewed since 2006, but either:

changes have been made to the recommendation wording that change the meaning, or

NICE has made editorial changes to the original wording to clarify the action to be taken.

Recommendations from NICE guideline CG43 that have been amended

Recommendations are labelled [2006, amended 2014] if the evidence has not been reviewed since 2006 but changes have been made to the recommendation wording that change the meaning, or NICE has made editorial changes to the original wording to clarify the action to be taken.

Recommendation in 2006 guideline

Recommendation in current guideline

Reason for change

The care of children and young people should be coordinated around their individual and family needs and should comply with national core standards as defined in the Children's NSFs for England and Wales.

1.1.4 Coordinate the care of children and young people around their individual and family needs. Comply with national core standards as defined in the Department of Health's A call to action on obesity in England.

Updated to reflect NICE house style and to reflect changes to national core standards from National Service Frameworks to A call to action on obesity in England.

The overall aim should be to create a supportive environment that helps overweight or obese children and their families make lifestyle changes.

1.1.5 Aim to create a supportive environment that helps a child who is overweight or who has obesity, and their family, make lifestyle changes.

Updated to reflect NICE house style. Footnote added to clarify the settings which could constitute 'environment'.

Body mass index (BMI) should be used as a measure of overweight in adults, but needs to be interpreted with caution because it is not a direct measure of adiposity.

1.2.2 Use BMI as a practical estimate of adiposity in adults. Interpret BMI with caution because it is not a direct measure of adiposity.

Updated to reflect NICE house style and to reflect Guideline Development Group consensus that BMI is a practical estimate of adiposity, as opposed to overweight.

Waist circumference may be used, in addition to BMI, in people with a BMI less than 35 kg/m2.

1.2.3 Think about using waist circumference, in addition to BMI, in people with a BMI less than 35 kg/m2.

Updated to reflect NICE house style and to include a footnote on the NICE public health guidance on waist circumference.

BMI (adjusted for age and gender) is recommended as a practical estimate of overweight in children and young people, but needs to be interpreted with caution because it is not a direct measure of adiposity.

1.2.4 Use BMI (adjusted for age and gender) as a practical estimate of adiposity in children and young people. Interpret BMI with caution because it is not a direct measure of adiposity.

Updated to reflect NICE house style and to reflect Guideline Development Group consensus that BMI is a practical estimate of adiposity, as opposed to overweight, and to reflect addition of footnote providing further information on the use of z scores.

BMI measurement in children and young people should be related to the UK 1990 BMI charts to give age- and gender-specific information.

1.2.12 Relate BMI measurement in children and young people to the UK 1990 BMI charts to give age- and gender-specific information.

Updated to reflect NICE house style and to reflect addition of footnote providing further information on the use of z-scores.

Patients and their families and/or carers should be given information on the reasons for tests, how the tests are performed and their results and meaning.

1.3.5 Give people and their families and/or carers information on the reasons for tests, how the tests are done, and their results and meaning. If necessary, offer another consultation to fully explore the options for treatment or discuss test results.

Updated to reflect NICE house style and combined with recommendation 1.2.3.6 from the original guideline.

After appropriate measurements have been taken and the issues of weight raised with the person, an assessment should be done, covering:

any environmental, social and family factors, including family history of overweight and obesity and comorbidities

the person's willingness and motivation to change lifestyle

the potential of weight loss to improve health

any psychological problems

any medical problems and medication

the role of family and care workers in supporting individuals with learning disabilities to make lifestyle changes.

Updated to reflect NICE house style and to reflect changing measurement of blood glucose to HBA1c. The recommendation was also edited to reflect the needs of people with learning disabilities.

Referral to specialist care should be considered if:

• the underlying causes of overweight and obesity need to be assessed

• the person has complex disease states and/or needs that cannot be managed adequately in either primary or secondary care

• conventional treatment has failed in primary or secondary care

• drug therapy is being considered for a person with a BMI more than 50 kg/m2

• specialist interventions (such as a very-low-calorie diet for extended periods) may be needed, or

• surgery is being considered.

1.3.7 Consider referral to tier 3 services if:

the underlying causes of being overweight or obese need to be assessed

the person has complex disease states and/or needs that cannot be managed adequately in tier 2 (for example, the additional support needs of people with learning disabilities)

conventional treatment has been unsuccessful

drug treatment is being considered for a person with a BMI more than 50 kg/m2

specialist interventions (such as a very-low-calorie diet) may be needed

surgery is being considered.

Updated to reflect NICE house style and to reflect service organisation changes to tiered services. Additions have also been made to reflect the needs of people with learning disabilities. Edits have been made to use more sensitive language and avoid the term failure

After measurements have been taken and the issue of weight raised with the child and family, an assessment should be done, covering:

environmental, social and family factors that may contribute to being overweight or obese, and the success of treatment

growth and pubertal status.

Any medical problems and medication

The role of family and care workers in supporting individuals with learning disabilities to make lifestyle changes.

Updated to reflect NICE house style and to reflect changing measurement of blood glucose to HBA1c. The recommendation was also edited to include additional points of clinical relevance that were in the adult recommendation but missing from the recommendation for children and young people by Guideline Development Group consensus. The recommendation was also edited to reflect the needs of people with learning disabilities.

Referral to an appropriate specialist should be considered for children who are overweight or obese and have significant comorbidity or complex needs (for example, learning or educational difficulties).

1.3.10 Consider referral to an appropriate specialist for children who are overweight or obese and have significant comorbidities or complex needs (for example, learning disabilities or other additional support needs.

Updated to reflect NICE house style and edit the language related to the learning disabilities population.

In secondary care, the assessment of overweight and/or obese children and young people should include assessment of associated comorbidities and possible aetiology, and investigations such as:

• blood pressure measurement

• fasting lipid profile

• fasting insulin and glucose levels

• liver function

• endocrine function.

These tests need to be performed, and results interpreted, in the context of the degree of overweight and obesity, the child's age, history of comorbidities, possible genetic causes and any family history of metabolic disease related to overweight and obesity.

1.3.11 In tier 3 services, assess associated comorbidities and possible causes for children and young people who are overweight or who have obesity. Use investigations such as:

blood pressure measurement

lipid profile, preferably while fasting

fasting insulin

fasting glucose levels and oral glucose tolerance test

liver function

endocrine function.

Interpret the results of any tests used in the context of how overweight or obese the child is, the child's age, history of comorbidities, possible genetic causes and any family history of metabolic disease related to being overweight or obese.

Updated to reflect NICE house style and to reflect changing service organisation to tiered services.

The results of the discussion should be documented, and a copy of the agreed goals and actions should be kept by the person and the healthcare professional or put in the notes as appropriate. Healthcare professionals should tailor support to meet the person's needs over the long term.

1.4.3 Document the results of any discussion. Keep a copy of the agreed goals and actions (ensure the person also does this), or put this in the person's notes.

Updated to reflect NICE house style and to remove an overlap with recommendation 1.2.4.4 in the original guideline.

Information should be provided in formats and languages that are suited to the person. When talking to patients and carers, healthcare professionals should use everyday, jargon-free language and explain any technical terms. Consideration should be given to the person's:

• age and stage of life

• gender

• cultural needs and sensitivities

• ethnicity

• social and economic circumstances

• physical and mental disabilities.

1.4.6 Provide information in formats and languages that are suited to the person. Use everyday, jargon-free language and explain any technical terms when talking to the person and their family or carers. Take into account the person's:

Updated to reflect NICE house style and to edit the language related to the learning disabilities population

People who are overweight or obese, and their families and/or carers, should be given relevant information on:

• overweight and obesity in general, including related health risks

• realistic targets for weight loss; for adults the targets are usually

- maximum weekly weight loss of 0.5–1 kg

- aim to lose 5–10% of original weight

• the distinction between losing weight and maintaining weight loss, and the importance of developing skills for both; the change from losing weight to maintenance typically happens after 6–9 months of treatment

• realistic targets for outcomes other than weight loss, such as increased physical activity, healthier eating

• diagnosis and treatment options

• healthy eating in general (see appendix D)

• medication and side effects

• surgical treatments

• self care

• voluntary organisations and support groups and how to contact them.

There should be adequate time in the consultation to provide information and answer questions.

1.4.8 Give people who are overweight or obese, and their families and/or carers, relevant information on:

being overweight and obesity in general, including related health risks

the distinction between losing weight and maintaining weight loss, and the importance of developing skills for both; advise them that the change from losing weight to maintenance typically happens after 6–9 months of treatment

realistic targets for outcomes other than weight loss, such as increased physical activity and healthier eating

diagnosis and treatment options

healthy eating in general

medication and side effects

surgical treatments

self-care

voluntary organisations and support groups and how to contact them.

Ensure there is adequate time in the consultation to provide information and answer questions.

Updated to reflect NICE house style and to include an up-to-date footnote cross-referencing the 'Weight Wise' campaign. In place of appendix D, a footnote has been added to cross-reference the NHS Choices: Healthy Eating website

Low-calorie diets (1000–1600 kcal/day) may also be considered, but are less likely to be nutritionally complete.

1.7.6 Consider low-calorie diets (800–1600 kcal/day), but be aware these are less likely to be nutritionally complete.

Updated to reflect NICE house style. The definition of low-calorie diet has been amended to reflect changes to the definition of a very-low-calorie diet by Guideline Development Group consensus and review of evidence.

In the longer term, people should move towards eating a balanced diet, consistent with other healthy eating advice.

1.7.11 Encourage people to eat a balanced diet in the long term, consistent with other healthy eating advice.

Updated to NICE house style and addition of a footnote referral to NHS Choices Healthy Eating website.

For overweight and obese children and adolescents, total energy intake should be below their energy expenditure. Changes should be sustainable.

1.7.14 For overweight and obese children and young people, total energy intake should be below their energy expenditure. Changes should be sustainable.

Updated to NICE house style including the use of the term young people, rather than adolescents.

In children younger than 12 years, drug treatment may be used only in exceptional circumstances, if severe life-threatening comorbidities (such as sleep apnoea or raised intracranial pressure) are present. Prescribing should be started and monitored only in specialist paediatric settings.

1.8.5 In children younger than 12 years, drug treatment may be used only in exceptional circumstances, if severe comorbidities are present. Prescribing should be started and monitored only in specialist paediatric settings.

Removal of 'life-threatening' and examples of severe life-threatening comorbidities deleted, as they were considered by the Guideline Development Group to be unhelpful in clinical practice.

In children aged 12 years and older, treatment with orlistat or sibutramine is recommended only if physical comorbidities (such as orthopaedic problems or sleep apnoea) or severe psychological comorbidities are present. Treatment should be started in a specialist paediatric setting, by multidisciplinary teams with experience of prescribing in this age group.

1.8.6 In children aged 12 years and older, treatment with orlistat is recommended only if physical comorbidities (such as orthopaedic problems or sleep apnoea) or severe psychological comorbidities are present. Treatment should be started in a specialist paediatric setting, by multidisciplinary teams with experience of prescribing in this age group.

Removed reference to sibutramine as marketing authorisation has been suspended for this drug.

Orlistat or sibutramine should be prescribed for obesity in children only by a multidisciplinary team with expertise in:

• drug monitoring

• psychological support

• behavioural interventions

• interventions to increase physical activity

• interventions to improve diet.

1.8.7 Do not give orlistat to children for obesity unless prescribed by a multidisciplinary team with expertise in:

drug monitoring

psychological support

behavioural interventions

interventions to increase physical activity

interventions to improve diet.

Updated to NICE house style and removal of reference to sibutramine as marketing authorisation has been suspended.

After drug treatment has been started in specialist care, it may be continued in primary care if local circumstances and/or licensing allow.

1.8.8 Drug treatment may be continued in primary care for example with a shared care protocol if local circumstances and/or licensing allow.

Updated to reflect NICE house style. Also added reference to the use of a shared care protocol to support prescribing decisions between specialist services and primary care in line with current practice to ensure safe prescribing.

If orlistat or sibutramine is prescribed for children, a 6–12 month trial is recommended, with regular review to assess effectiveness, adverse effects and adherence.

1.9.11 If orlistat is prescribed for children, a 6–12 month trial is recommended, with regular review to assess effectiveness, adverse effects and adherence.

Updated to remove sibutramine and include a footnote highlighting that the use of orlistat in children and young people is outside its marketing authorisation.

Bariatric surgery is recommended as a treatment option for people with obesity if all of the following criteria are fulfilled:

they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight

all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months

the person has been receiving or will receive intensive management in a specialist obesity service

the person is generally fit for anaesthesia and surgery

the person commits to the need for long-term follow-up.

See recommendations 1.7.6.12 and 1.7.6.13 for additional criteria to use when assessing children, and recommendation 1.7.6.7 for additional criteria for adults.

1.10.1 Bariatric surgery is a treatment option for people with obesity if all of the following criteria are fulfilled:

They have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight.

All appropriate non-surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss.

The person has been receiving or will receive intensive management in a tier 3 service

The person is generally fit for anaesthesia and surgery.

The person commits to the need for long-term follow-up.

See recommendations 1.10.12 and 1.10.13 for additional criteria to use when assessing children, and recommendation 1.10.7 for additional criteria for adults. See also recommendations 1.11.1–1.11.3 for additional criteria for people with type 2 diabetes.

Updated to NICE house style and edits have been made to use more sensitive language and avoid the term 'failure'.

Arrangements for prospective audit should be made, so that the outcomes and complications of different procedures, the impact on quality of life and nutritional status, and the effect on comorbidities can be monitored in both the short and the long term.

1.10.5 Arrange prospective audit so that the outcomes and complications of different procedures, the impact on quality of life and nutritional status, and the effect on comorbidities can be monitored in both the short and the long term.

Updated to reflect NICE house style and include a footnote cross-referencing the National Bariatric Surgery Register.

The surgeon in the multidisciplinary team should:

have undertaken a relevant supervised training programme

have specialist experience in bariatric surgery

• be willing to submit data for a national clinical audit scheme.

1.10.6 The surgeon in the multidisciplinary team should:

have had a relevant supervised training programme

have specialist experience in bariatric surgery

submit data for a national clinical audit scheme.

Updated to reflect NICE house style and include a footnote cross-referencing to the National Bariatric Surgery Register.

Surgical care and follow-up should be coordinated around the young person and their family's needs and should comply with national core standards as defined in the Children's NSFs for England and Wales.

1.10.15 Coordinate surgical care and follow-up around the child or young person and their family's needs. Comply with the approaches outlined in the Department of Heath's A call to action on obesity in England.

Updated to reflect NICE house style and to reflect changes to national core standards from National Service Frameworks to A call to action on obesity in England

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of 'The guidelines manual' (January 2009). This does not apply to any recommendations ending [2006] (see 'Update information' above for details about how recommendations are labelled). In particular, for recommendations labelled [2006] the word 'consider' may not necessarily be used to denote the strength of the recommendation.

Other versions of this guideline

The full guideline, Obesity, contains details of the methods and evidence used to develop the guideline. It is published by the National Clinical Guideline Centre.

The recommendations from this guideline have been incorporated into a NICE pathway.

Implementation

Your responsibility

This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summaries of product characteristics of any drugs.

Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.